Fragility fractures associated with osteoporosis (OP) reduce quality of life, increase risk for subsequent fractures, and are a major economic burden. In 2010, Osteoporosis Canada produced clinical practice guidelines on the management of OP patients at risk for fractures (Papaioannou et al. CMAJ 2010). We describe the real-world incidence of primary and subsequent fragility fractures in elderly Canadians in Ontario, Canada in a timespan (2011–2017) following guideline introduction.

This retrospective observational study used de-identified health services administrative data generated from the publicly funded healthcare system in Ontario, Canada from the Institute for Clinical Evaluative Sciences. The study population included individuals ≥66 years of age who were hospitalized with a primary (i.e. index) fragility fracture (identified using ICD-10 codes from hospital admissions, emergency and ambulatory care) occurring between January 1, 2011 and March 31, 2015. All relevant anatomical sites for fragility fractures were examined, including (but not limited to): hip, vertebral, humerus, wrist, radius and ulna, pelvis, and femur. OP treatment in the year prior to fracture and subsequent fracture information were collected until March 31, 2017. Patients with previous fragility fractures over five years prior to the index fracture, and those fractures associated with trauma codes, were excluded.

115,776 patients with an index fracture were included in the analysis. Mean (standard deviation) age at index fracture was 80.4 (8.3) years. In the year prior to index fracture, 32,772 (28.3%) patients received OP treatment. The incidence of index fractures per 1,000 persons (95% confidence interval) from 2011–2015 ranged from 15.16 (14.98–15.35) to 16.32 (16.14–16.51). Of all examined index fracture types, hip fractures occurred in the greatest proportion (27.3%) of patients (Table). The proportion of patients incurring a second fracture of any type ranged from 13.4% (tibia, fibula, knee, or foot index fracture) to 23% (vertebral index fracture). Hip fractures were the most common subsequent fracture type and the proportion of subsequent hip fractures was highest in patients with an index hip fracture (Table). The median (interquartile range [IQR]) time to second fracture ranged from 436 (69–939) days (radius and ulna index fracture) to 640 (297–1,023) days (tibia, fibula, knee, or foot index fracture). The median (IQR) time from second to third fracture ranged from 237 (75–535) days (pelvis index fracture) to 384 (113–608) days (femur index fracture).

This real-world study found that elderly patients in Ontario, Canada incurring a primary fragility fracture from 2011–2015 were at risk for future fractures occurring over shorter periods of time with each subsequent fracture. These observations are consistent with previous reports of imminent fracture risk and the fragility fracture cascade in OP patients (Balasubramanian et al. ASBMR 2016, Toth et al. WCO-IOF-ESCEO 2018). Overall, these data suggest that in elderly patients with an index fragility fracture at any site (with the exception of the radius or ulna), the most likely subsequent fracture will occur at the hip in less than 2 years.

It is recognised that as the severity of hallux valgus (HV) worsens, so do the clinical and radiological signs of arthritis in the first metatarsophalangeal joint.

However, few studies specifically document the degenerate changes. The purpose of this study is to determine if intraoperative mapping of articular erosive lesions of the first MTP joint can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity.

Introduction

The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture.

Purpose

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients.

Purpose

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients.

Purpose: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Knee Arthroplasty (TKA).

Methods and Results: Our organisation has instituted a regime covering all aspects of the peri-operative care for TKA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary TKA in the six months from January to June 2008 (total of 319 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks.

A total of 305 TKAs with complete data sets were included in the analysis. Of these 36% were mobilised on the day of surgery and 93% by post-operative day 1. Catheterisation rates were 12% and the need for postoperative intra-venous fluids was 10%. In-house physiotherapy discharged 58% of patients by day 3 and 85% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (median = 3) and 80% of patients experienced no nausea or vomiting.

Functionally, the median range of movement at discharge was 85° with 31% of patients requiring out-patient physiotherapy assessment. At six weeks the median range of motion was 95° with only 5% of patients having a reduced range of motion (reduction of > 10°) when compared to discharge. The median Oxford scores improved from 43 pre-operatively to 26 at six weeks.

Conclusion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia.

Introduction: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Hip Arthroplasty (THA).

Methods: Our organisation has instituted a regime covering all aspects of the peri-operative care for THA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary THA in the six months from January to June 2008 (total of 138 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks.

Results: A total of 122 THAs with complete data sets were included in the analysis. Of these 27% were mobilised on the day of surgery and 97% by post-operative day 1. Catheterisation rates were 16% and the need for post-operative intra-venous fluids was 15%. In-house physiotherapy discharged 58% of patients by day 3 and 87% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (medians were 2.5 and 2 respectively) and 84% of patients experienced no nausea or vomiting.

Functionally 14% of patients required out-patient physiotherapy assessment. At three months the median Oxford scores had improved from 43 pre-operatively to 20.

Discussion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia.

The best type of stem fixation for revision hip arthroplasty is still controversial with regard to medium and long tem results. We wanted to ascertain the medium term results of revision hip arthroplasty using cemented collarless polished tapered femoral stem.

Methods: 44 hips in 39 patients (23 female, 16 male) who had revision THR for aseptic loosening with a minimum follow-up of 10 years were reviewed clinically, radiographically and by using the oxford hip score. Flanged cemented polyethylene cup and polished tapered cemented stem were used. Clinical and radiological evidence of failure and revision rates were determined. Details of grafting and reinforcement required at surgery and any complications in the operative and postoperative period were noted.

Results: The mean age of patients was 70 years (range 35–87 years). Femoral component alone was revised in 2 hips and both cup and stem were revised in 42 hips. Impaction grafting for acetabulum was required in 16 hips and for femur in 5 hips. Failure rate, with revision or excision arthroplasty as the end point, was 13.6% (Total 6 hips – cup and stem in 2 hips, cup only in 3 hips and excision arthroplasty with spacer for infection in 1 hip). The survival rate for femoral stem was 93% and for acetabular cup was 86%. Heterotopic ossification was seen in 9 hips, trochanteric bursitis in 5, short term thigh pain in 3. Mean last Oxford hip score was 30.5/60.

Conclusion: Revision hip arthroplasty using cemented tapered polished stem provides good results at 10 – 13 year follow-up.

A descriptive study of osteoporotic fractures and the evaluation of the relative risk of hip fracture following a minor fracture were done on 2.5 million individuals from 1980 to 1997. People aged forty-five years old and older have a risk for hip fracture after a minor fracture of 2.3–17.3 time the risk of people without previous fracture. Given the availability of pharmaceuticals that decrease the fracture risk dramatically within the first 18 months of therapy, the average four to six years time between minor and hip fracture represents a perfect window of opportunity for preventive treatment.

Osteoporotic fractures, especially hip fractures, represent a major health problem in terms of morbidity, mortality and cost. Since the availability of new treatments for osteoporosis, a better understanding of the disease is needed to define the indications for treatment.

A descriptive study of osteoporotic fractures and the evaluation of the relative risk of hip fracture following a minor fracture were done on a population aged fortyfive years old and older from 1980 to 1997 (2.5 million individuals).

During the follow-up period, 220,120 fractures (hip, wrist, proximal humerus and ankle) were recorded. Wrist fractures were the most frequent (42.2%) followed by hip fractures (32.5%). Although the proportions of fracture sites were similar for both sexes, 75% of the fractures occurred in females. The mortality rate 1 year after a hip fracture is increased by 14–27% for men and 9–13% for women. Men and women aged fortyfive years old and older have a risk for hip fracture after a humerus or a wrist fracture of 2.3–17.3 time the risk of people without previous fracture. The average time between a wrist or humerus fracture and a hip fracture was four to six years.

Wrist and humerus fractures represent a major risk for future hip fracture. Given the availability of pharmaceuticals that decrease the risk of hip fracture dramatically within the first eighteen months of therapy, the interval between minor and hip fracture represents a perfect window of opportunity for preventive treatment to decrease the risk of future hip fracture.

Introduction and Aims: Osteoporotic fractures, especially hip fractures, represent a major health problem in terms of morbidity, mortality and cost. Since the availability of new treatments for osteoporosis, a better understanding of the disease is needed to define the indications for treatment.

Method: A descriptive study of osteoporotic fractures and the evaluation of the relative risk of hip fracture following a minor fracture were done on a population aged 45 years old and older from 1980 to 1997 (2.5 million individuals, 1997).

Results: During the follow-up period, 220,120 fractures (hip, wrist, proximal humerus and ankle) were recorded. The incidence rate of fractures was stable over time. The wrist fracture was the most frequent (42.2%), followed by the hip fracture (32.5%). Although the proportions of fracture sites were similar for both sexes, 75% of the fractures occurred in females. The mortality rate one year after a hip fracture is increased by 14–27% for men and 9–13% for women after 60 years of age. Men and women aged 45 years old and older have a risk for hip fracture after a humerus or a wrist fracture of 2.3–17.3 time the risk of people without previous fracture.

Conclusion: Wrist and humerus fractures represent a major risk for future hip fracture, prevention of hip fracture should be revaluated regarding these new data and all these patients should be evaluated for osteoporosis and receive the appropriate treatment.

Aims: To investigate the optimal dimension interference screw for fixation of a tendon graft in a bone tunnel. Methods: A porcine model was developed to represent ACL reconstruction in the distal femur. A standard 8mm size pig flexor tendon graft was inserted into a standard 8mm bone tunnel. The screw dimensions were varied. The tendon was loaded with a constant force using a Universal Testing Machine. The construct was tested to failure at a rate of 50mm/minute. Load, deformation data and mechanism of construct failure were recorded. The screw diameters of 7, 8 and 9mm and lengths of 20, 25 and 30mm were tested in 80 individual reconstructions. Results: The mean pull out force was similar between the 7mm (191N) and 8mm screws (188N), but significantly different for the 9mm screw (109N) (p< 0.05) The 30mm screw (231N) was marginally better than the 20mm screw (215N) (p> 0.05). The mechanism of failure however, was significantly different between the groups. All grafts fixed with a 9mm screw failed at the tunnel opening (100%), whereas those fixed with a 7mm screw failed by slippage of the graft along the length of the tunnel (83%). The screw length did not affect the mechanism of graft failure. Conclusion: Our results suggest that a screw size equal to or 1mm less than the diameter of the tunnel gives the optimum initial interference screw fixation of tendon in a bone tunnel.

We report the result of 46 patients (30 female, 16 male) with periprosthetic femoral fractures who underwent insertion of the Kent Hip Prosthesis. Average age was 73 years (range 43–96years) and follow-up ranged from one to seven years (average, 4 years). The primary implants involved were as follows: Charnley (26), Austin Moore (6), Howse (5), Custom (4), Exeter (1), DHS (1), Thompson (1) and Richards (1). Average time to fracture from insertion of the primary implant ranged from 3 weeks to 20 years (average, 8 years). Forty cases were post-primary implant fractures (38 traumatic, 2 atraumatic) and 6 occurred intraoperatively. Using the Johanssen classification there were 12 type I, 30 type II and two type III fractures. Of the 46 cases, prior to fracture, 42 were living in their own home, 24 were mobile unaided and 20 had thigh and/or groin pain. Thirty-two had a loose stem and/or cup assessed at the time of surgery. Operating time was on average 143 mins (65–235mins). At latest follow-up, 43 were living in their own home, 5 were walking unaided and 10 had ongoing pain. In 34 cases complete union was achieved. There were no cases on non-union. Three patients required revision surgery for broken stems. Three patients sustained wound infections and there were six posterior dislocations. All of the complications were treated satisfactorily. We conclude that the Kent Hip Prosthesis is a useful option in the management of periprosthetic femoral fractures.